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Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

This is a disorder of the inner ear caused by a change in fluid volume in the labyrinth. If the cause is known, the condition is more properly called Ménière's syndrome.

In the inner ear are the cochlea (for hearing) and the vestibular apparatus (for balance). The vestibular apparatus is a set of tubes enclosed by the membranous labyrinth. The membranous labyrinth contains fluid called endolymph.

In Ménière's disease there is a progressive distension of the membranous labyrinth, which is called 'endolymphatic hydrops'. This may injure the vestibular system, causing vertigo; or the cochlea, causing hearing loss.[1]

The condition is diagnosed on the basis of the following three factors:

Symptoms

Core symptoms are vertigo, tinnitus and fluctuating hearing loss with a sensation of aural pressure. The hallmark of the disease is its fluctuating and episodic pattern of symptoms:

Acute attacks typically last minutes-hours, often 2-3 hours.

Acute episodes may occur in clusters of about 6-11 per year.

Remission of symptoms may last several months.

Most patients develop unilateral symptoms initially. Bilateral symptoms may develop, often many years later.

Other symptoms:

Some patients have 'drop attacks', ie sudden unexplained falls without loss of consciousness or associated vertigo. This is reported in about 4% of Ménière's disease patients.

Imbalance is sometimes reported. This tends to occur once the spinning sensation has decreased.

Three stages of disease are described, although patients do not necessarily progress through all these:[5]

Early-stage - predominantly vertigo attacks which are sudden and unpredictable. Hearing worsens and tinnitus increases. There is good recovery between attacks; these remissions can last days-years.

Middle-stage - continuing episodes of vertigo; there may be giddiness before and after attacks. Sensorineural hearing loss develops. Tinnitus also progresses. Periods of remission vary; they may last several months.

Many other conditions can present with vertigo, tinnitus or deafness. (It is the combination that helps to diagnose Ménière's disease.) In primary care, common causes of vertigo are BPPV, acute vestibular neuronitis and Ménière's disease.

MRI brain scan - is advised for unilateral cases of Ménière's disease, to exclude other causes of unilateral vertigo and hearing loss - eg, acoustic neuroma. This should include views of the internal auditory canal, with and without contrast.

Standard lateral mastoid radiographs - can aid diagnosis by documenting the forward location of the sigmoid sinus, seen in almost all patients with Ménière's disease.[4]

Drivers of any type of vehicle are required to send a form to the Driver and Vehicle Licensing Agency (DVLA) - available from their website - if they have vertigo, irrespective of the cause. Each case is taken on its own merits. Factors taken into consideration include whether attacks are preceded by a warning, how disabling they are, whether medication has been started and whether the condition is under control.

Treatment

The aim of therapy is to:

Alleviate acute attacks.

Reduce severity and frequency of attacks.

Improve hearing and reduce the impact of tinnitus.

Acute attacks

Vertigo and nausea can be alleviated by prochlorperazine, cinnarizine, cyclizine, or promethazine.

If there is vomiting, buccal or intramuscular doses may be needed.

Consider patient preference for both choice of drug and route of administration.

For severe symptoms, hospital admission may be needed to maintain hydration.

Intramuscular steroid injection followed by a tapering dose of oral steroids has also been recommended.[2]

Lifestyle measures may be helpful. Low-salt diet and avoiding caffeine, chocolate, alcohol and tobacco are often advised. Excessive fatigue appears to be a trigger factor in some patients and should be avoided. Evidence to support these measures is, however, lacking.

Drug prophylaxis:

Consider a trial of betahistine (initially 16 mg three times a day) to reduce the frequency and severity of attacks.

Diuretics may be helpful but are not usually recommended for use in primary care.

These seem to be effective in some situations - eg, for stable vestibular loss or for stable, unilateral vestibular disease.

The programmes involve exercises such as learning to bring on the symptoms to 'desensitise' the vestibular system; learning to improve balance, co-ordination and coping skills.

Maintain mobility:

After an acute attack of vertigo, patients naturally tend to sit still. Encourage them to move around to promote central compensation, where the brain uses vision and other senses to compensate for the loss of vestibular function.

This is known as transtympanic gentamicin perfusion, transtympanic gentamicin injection or intratympanic gentamicin injection.

The aim is to use the damaging action of gentamicin on the sensorineural epithelium and labyrinthine cells to reduce vertigo, while preserving hearing (although there may be a risk of sensorineural hearing loss).

Micropressure therapy has been endorsed by the National Institute for Health and Care Excellence (NICE). This involves inserting a grommet via the eardrum into the middle ear and blowing air at low pressure into the inner ear. The aim is to reduce pressure in the ear, thus obviating the need for more invasive surgery.[12]

Labyrinthectomy - this is a last option, as hearing in that ear would also be lost.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.